“Your mouth is a window into the health of your body.”~American Dental Association (1)

As a dietitian, I am very passionate about nutrition care, dental health, and good oral care. The mouth is not only the window into the health of your body, it is also the first route of nutrition. If you have oral or dental health issues and cannot eat the nutritious foods your body needs, we have a problem.

Taking care of oral health is more important than just preventing pain or bad breath. In older adults, it can be the difference between life and death. Sounds like I’m being dramatic? Keep reading… and don’t forget to brush and floss today. 😉

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Senior Dental Care

Myth of the day:Losing your teeth is part of getting older.

The reality is that losing your teeth is nota normal part of health aging. With proper care, an older adult can keep most, if not all their teeth. Dentures are not the expected outcome of aging.

However, if someone doesn’t take care of their dental health, there are consequences. And some are more severe than just losing their teeth. Let’s take a look at some common dental problems specific to the elderly.

Common Geriatric Problems

Common oral health problems (and problems that contribute to poor oral health) in the geriatric population include (2):

All these factors contribute to a greater level of risk when it comes to oral health in the elderly.

One in five older adults have untreated dental caries. Two in three have gum disease. And many more take medications (both prescribed and over the counter) that can cause dry mouth, increasing the risk of cavities (2).

We know that older adults are at an increased risk for oral health problems, but who is at the greatest risk?

The older adults with the most dental problems typically have the least amount of money and no insurance. Minorities are also at a greater risk of having more dental problems. Other risk factors include being disabled, homebound, or living in a nursing home (2).

Xerostomia in Older Adults

Xerostomia is a fancy word for “dry mouth.” It refers to a lack of saliva in the mouth. Saliva has so many important functions most of us never think about. Saliva lubricates our mouth, keeps it clean, aids in chewing and swallowing, help us to taste, and even has a role in speaking.

Without saliva, food and bacteria can hang out on the teeth and gums longer increasing the risk of dental caries and gum disease. Less spit = more dental problems.

Being on a lot of medications is often a culprit for dry mouth. So many medications list dry mouth as a side effect. But research is suggesting that older adult may have reduced salivary flow, regardless of medication (3).

So, in a nutshell, we see more dry mouth in older adults than any other age group. Dry mouth is a major issue in managing oral health in the elderly.

What do we do about it? We treat it, it’s a part of dental care and taking care of oral health.

Salivary stimulants and artificial saliva are other potential options for those with dry mouth. Speak to your medical and dental health care team to find out the best options for each individual situation.

Treating dry mouth is also very important for older adults at very end of life.

Missing Teeth and Dentures

We’ve already covered that losing your teeth is not a normal part of healthy aging. But we know many people have lost their teeth. You may wonder how many people this affects. The Center for Disease Control (CDC) has some really cool maps that show the rates of dental issues by state in the U.S.

According to CDC data, in 2016 14.4% of older adults in the U.S. has lost all of their natural teeth due to decay or gum disease. This is actually down from 16.2% in 2012. Rates increase with lower levels of education and income (5).

While a complete loss of teeth isn’t very common in the elderly, many more have missing teeth. According to CDC data, in 2016 36% of older adults in the U.S. have lost 6 or more teeth due to decay or gum disease (5).

So, if you do the math, approximately 50% of older adults are missing some, if not all, of their teeth. On the flip side, another 50% of older adults have nearly all of their natural teeth.

What is Good Dental Hygiene?

As a geriatric dietitian, I always ask my patients if they brush and floss.

It’s a surprisingly uncomfortable question for some. What’s more surprising is how few people I encounter who actually brush their teeth on a daily basis. And how rare it is to find someone who flosses daily.

But almost every time they answer yes to both brushing and flossing, they still have their natural teeth.

So, what is good dental hygiene for the older adult?

Brushing and Flossing

A key to good dental hygiene is as simple as it sounds: brushing and flossing your teeth every single day.

Older adults (and everyone for that matter!) should be brushing their teeth twice per day with a fluoridated toothpaste. Use a soft bristle tooth brush and be sure to replace it every 3-4 months (6).

In addition to brushing, older adults should be flossing every day. You can use traditional string floss or pre-threaded floss picks, water flossers (like a Waterpik Water Flosser*), or wooden plaque removers (6). The key is cleaning those tiny, tight spots in between the teeth. This is where cavities like to grow.

Brushing and flossing is not only good for your mouth- it’s good for your wallet. It’s a low-priced investment compared to the astronomical cost of dental care to treat cavities and gum disease.

Denture Care

You may think an older adult without teeth doesn’t have to worry about dental care – but that is an incorrect assumption. Bacteria sticks to dentures the exact same way they stick to natural teeth. Plus, food can get stuck under the dentures causing sores and pains. Ouch.

Whether an older adult has full dentures or partial dentures, they should be removed every single day (6). Don’t just clean the dentures. Brush the gums, tongue, and roof of the mouth with a soft bristle tooth brush. Be sure to check for any sores in the mouth.

When cleaning dentures, work over a basin of water (or a plugged sink filled with a small layer of water) just in case you drop your dentures – you don’t want to break them!

To clean the dentures, first rinse any obvious food particles. Then use a soft bristle toothbrush and a non-abrasive cleaner to clean the dentures. Brush the dentures thoroughly and rinse. Do this every single day.

Other Recommended Habits

Other recommended habits for good dental hygiene include drinking water with fluoride. Fluoride can help prevent cavities. Check to see if your community has fluoridated water, if not consider purchasing bottled water with fluoride. Keep in mind some water filters can remove fluoride (6).

Smoking is really bad for your health – that’s no secret. But did you know it’s also bad for your dental health? Smoking can increase risk of cavities, gum disease, and losing teeth. It can also make it harder for any wounds in the mouth to heal (6). No matter the age, it’s never too late to quit smoking.

We would be remiss if we didn’t talk about the role of nutrition in good oral hygiene. Eating a healthy balanced diet can contribute to a healthy mouth. Getting good nutrients through food including calcium, vitamin D, and phosphorous are good for the teeth.

Foods high in sugar can cause tooth decay. The worst offenders are those sweets that you suck on for a long time, sticky/chewy foods (from candy to dried fruit) that can leave sugar stuck to your teeth for an extended period, and sugary drinks (like soda and juice).

A good idea would be to limit these foods. Or at least rinse out the mouth with water after eating these sugary culprits. Or better yet, brushing your teeth after eating these foods.

The final, maybe even most important habit, is to see the dentist on a regular basis. At least annually for exams, preferably every 6 months or sooner for dental cleanings. Catching dental issues early can save you a lot of money, pain, and headache.

Health Risks of Poor Oral Hygiene

We’ve covered lots reasons why older adults are AT RISK for oral health issues, but now let’s shift gears. Let’s talk about the health RISKS OF poor oral hygiene. What happens if the mouth isn’t taken care of. What risk is there to the older adult?

Poor oral hygiene can cause pain, make eating difficult, cause weight loss, contribute to disease, and can affect relationships & social interactions. Taking care of teeth and the mouth matters.

A commonly overlooked implication of poor oral health are the psychological and social implications it can have. Missing teeth, discolored/rotted teeth, inflamed gums, bad breath, and visible wounds can impact self-image. It can cause embarrassment, social isolation, depression, and negatively affect quality of life.

This affects overall health. This can even affect nutritional health (eating less because you feel cruddy can lead to malnutrition). As a dietitian I have two unique concerns related to poor oral health in older adults: malnutrition and aspiration pneumonia.

These conditions are what I was alluding to at the start of this post (remember, “life and death”). Malnutrition and aspiration pneumonia are serious and life-threatening conditions.

How are these related two related oral health? Well let me explain the “big two.”

Malnutrition

Older adults are at an increased risk for malnutrition. Malnutrition is what happens when your body doesn’t get the nutrition it needs. It can lead to an unhealthy loss of fat and muscle.

This leads to a decline in functional status (ability to move), independence, bone mass, immune function, and overall heath. Malnutrition is also associated with high hospitalization rates and increased morality (7). This is bad news for older adults.

Research tells many older adults are at risk for or have malnutrition. Rates of malnutrition vary. Among older adults in Europe and North America, malnutrition is present in 1-15% of those living independently, 25-60% of those in geriatric care facilities, and 35-65% of those in hospitals (7).

What does malnutrition have to do with oral health? Well, we know that poor oral health happens to be a risk factor for malnutrition.

When you have pain in your mouth as a result of poor oral hygiene, it makes sense you will eat less. If you are an older adult with diminished ability to taste, poor appetite, and on a lot of medications that make you not hungry, you might just skip eating all together. Eating becomes a chore, painful, dreaded.

Or perhaps certain foods or food groups will be avoided all together. They find a few different foods they can tolerate and that is all they eat. Without adequate nutrition, calories, and protein, unintended weight loss and malnutrition can result.

Taking care of oral health in seniors reduces the risk of malnutrition. It is a hidden risk you can avoid through taking care of the teeth.

Aspiration Pneumonia

Next let’s talk dysphagia and aspiration pneumonia. Dysphagia is difficulty swallowing. Approximately 15% of older adults have dysphagia or difficulty swallowing (8).

Difficulty swallowing can increase the risk of malnutrition in the same way pain in the mouth can- individuals with difficulty swallowing may be likely to avoid foods or eat less.

But those with dysphagia are also at an increased risk for aspiration pneumonia. This is when food or liquid intended for the stomach gets into the lungs (8). This usually means a trip to the hospital and a myriad of health complications.

Aspiration pneumonia can lead to longer hospital stays, longer lengths of disability, malnutrition, and even death. The risk of aspiration pneumonia and the likelihood of death from it increases with age (8). This is a serious condition that we want to avoid at all costs.

Now if an older adult has poor oral hygiene and bacteria in their mouth, what happens when they swallow their saliva? There is a chance it can “go down the wrong tube” and cause aspiration pneumonia. Even when they did “everything right”.

Research has shown that good oral hygiene may help prevent aspiration pneumonia. This includes regular cleanings, removing plaque from the teeth, gums, and dentures. Oral antimicrobial rinses may also be beneficial (9).

We could benefit from more research in this area, but one thing is for sure- oral hygiene is important!

Heart Health

As a dietitian, malnutrition and aspiration pneumonia are biggies because there are unintended consequences that can have life or death implications. But there are many other conditions linked to poor oral hygiene. Ones that can also contribute to mortality. Like heart health.

The health of your teeth is linked to the health of your heart.

While we don’t entirely know why, we do know that poor oral health is linked to heart disease. Poor oral hygiene causes an increase in oral bacteria, inflammation, and infection. Bacteria from the mouth can spread through your blood stream and bring bacteria to other parts of your body, including your heart (10).

Poor oral hygiene and the spread of oral bacteria has been linked to clogged arteries, stroke, and endocarditis (10). Endocarditis is an infection of the inner lining of the heart and heart valves. The heart can actually become infected through bacteria in the mouth- the body can do strange things.

Barriers to Dental Care

It’s pretty easy to give tips on good oral care- brush your teeth, floss, see the dentist! But the reality is there are many barriers to receiving good dental care among older adults. Real issues than need to be addressed.

Common Barriers and Issues

Older adults typically live on a fixed income and dental care can be expensive. Many older adults no longer have dental insurance after retiring and dental care services are extremely limited in Medicare (11). Options for dental insurance are limited and still can be expensive.

Many older adults are home bound and havelimited means to get to the dentist. Older adults who don’t speak English may face additional barriers for getting dental care including adequate translation (11).

Older adults with functional or cognitive decline face barriers to receiving dental care daily. And for older adults who have lived a lifetime of poor dental habits – change can be hard. These are daily habits that have been instilled over a lifetime. While change is hard, it can happen.

Then there can be a lack of awareness that they need good oral care. There can be a misconception that because of their age or because they wear dentures, they don’t need to see a dentist or take care of their oral health. They may be unaware of the risks associated with poor oral hygiene.

And let’s also mention fear of dental procedures. Dental anxiety is a real thing. And it can lead to avoidance of dental care. This is a legitimate issue that should be addressed if present.

So, let’s look at a couple of these barriers a little closer.

Dental Insurance for Seniors

A major barrier to accessing dental care for seniors is lack of insurance. It’s estimated that half of older adults living independently haven’t seen a dentist in over a year (11). The primary reason for this is usually financial – not enough money.

Medicare only covers specific medically necessary procedures in older adults. And what is offered at the state level varies greatly. Many state Medicaid programs don’t cover any dental services for seniors (11).

And for those with dental insurance, the coverage doesn’t go far. Even with dental insurance many older adults still have a large out of pocket cost which increases with age (11).

As a result, many older adults opt to not receive dental care at all, resulting in continued decline in oral health. Or they choose to have their teeth pulled, resulting in difficulty chewing and other potential nutrition issues (11).

Functional and Cognitive Decline (Caregivers need to help!)

Sick, frail older adults with functional or cognitive decline need help with cleaning their teeth. This includes brushing and flossing. Ensuring food isn’t pocketed in the cheeks, leaving food on the surface of the tooth or gums.

What do I mean by functional or cognitive decline?

For functional decline, I mean that the older adult is physically unable to brush their teeth. This may be due to the effects of a stroke, extreme weakness, paralysis, significant arthritis or pain, or diminished hand-grip strength (they can’t hold or maneuver a toothbrush).

For some, using an electric toothbrush may be enough to help. Others may need adaptive teeth cleaning equipment. They may need a tooth brush with a bigger handle if they cannot grip a standard toothbrush. They may need a device to help them hold their toothbrush (a holder or a rubber band).

Others will require assistance from someone else, providing physical assistance and brushing their teeth for them.

For cognitive decline, I mean the older adult cannot remember how to brush or when to brush. This may be due to Alzheimer’s disease or dementia or any other mental health disorder. Even if you provided the proper supplies, they either would not use them or would not use them properly.

Additionally, older adults with cognitive decline are typically on drugs that can cause dry mouth. And this group has been shown to have more issues with dry mouth in general.

A study looking at 200 individuals with cognitive decline found more than 70% of study participants had dry mouth – regardless of medications (12). As discussed previously dry mouth can contribute to an increased risk of cavities and poor oral health.

This group of older adults almost always require assistance with dental care. Whether it’s verbal cuing (i.e. providing a reminder – even cues on how to brush) or providing physical assistance and brushing their teeth for them.

I cannot emphasize this point enough. If you are a caregiver to an older adult with functional or cognitive decline – are you helping that individual with their oral care? If not, that’s OK… but start today! They rely on you and they cannot do this alone.

Dentures for Seniors

We’ve covered a lot on why oral health is so important for older adults, but let’s switch gears back to address dentures for seniors. We are going to take a moment to cover the different types of dental prostheses and how dentures can affect eating.

Sometimes seniors, frustrated by the cost and time of proper dental treatment, may just want to remove all their teeth and get dentures. It may seem like an easier and more affordable fix, but it is neither.

Dentures should be a last-ditch effort, not a first go-to. Dentures are nowhere near an exact substitute for teeth. But they are a good alternative for those without any other choice.

Types of Dental Prostheses

When teeth are missing there are typically four options for seniors – depending on which teeth are missing and their overall oral health: bridges, partial dentures, full dentures, and implants.

A bridge is a permanent fixture in the mouth. It covers the space where one or more teeth may be missing. A bridge is attached to the surrounding teeth. Partial dentures are similar, but they are removable and have a framework that attaches to surrounding teeth.

Keep in mind with these types of prostheses you need the surrounding teeth to keep them in place. This means you need to be brushing and flossing the remaining teeth in the mouth. If an anchor tooth gets decayed and needs removal, bridges and partial dentures attached to that tooth will no longer work.

Full dentures are removable. They are for those who have lost all their teeth on the upper and/or lower portion of the mouth. A dental implant replaces a single missing tooth by surgically placing an implant into the jaw bone.

Older adults may have a combination of these 4 options. Perhaps full upper dentures and a partial lower denture. Or they could have a full set of upper and lower dentures. Or a bridge and some implants.

Please know that dentures are not intended to last forever. Dentures can get worn out and the gums can shrink or change shape. Elderly who experience significant unintended weight loss often experience looser fitting dentures.

In general, dentures last 5-8 years; though you’d be surprised how long some older adults have had their dentures!

Eating with Dentures

Eating with dentures is not the same as eating with natural teeth. Getting dentures is a major adjustment and can take some getting use to.

The fit can feel uncomfortable. Dentures that haven’t been properly fitted can be loose or painful. Foods can sneak under dentures. Foods can taste different. And chewing can still be a challenge.

Individuals with full dentures only have one fifth to one fourth of the bite strength of those with natural teeth (12). This means the force for which you would bite food with natural teeth decreases significantly with dentures. This can be a real shift and even a letdown for new denture wearers.

Dentures are not the same as natural teeth.

Seniors with dentures can still have trouble chewing and new challenges with eating. This can have a negative impact on their diet quality and lead to food avoidance (13). Never assume that because someone had dentures, they don’t have problems chewing or eating.

Or that they wear them when they eat.

Eating Without Dentures

Many older adults choose not to use their dentures to eat due to a poor fit, inconvenience, discomfort, or frustration.

A study of over 600 older adults in rural US found that 18% of participants always removed dentures when eating and 27% sometimes removed dentures when eating. Those who removed their dentures to eat the most had the lowest dietary quality (13).

We prefer to see older adults eating with dentures. It improves the variety of foods they can eat and therefore improves their diet quality. A big barrier is the cost of dentures. Getting dentures fixed or replaced when the fit becomes poor may be a challenge.

However, keep in mind that dentures are important for more than just eating.

When teeth are missing, a senior’s facial profile may become unrecognizable to them. Facial muscles sag making them look older. Beyond eating, dentures can give older adults confidence in their appearance and smile. This is an important thing.

Chewing Difficulty

Sometimes their dental problems have existed so long, they don’t even consider chewing difficulty to be a problem. It’s something they have dealt with for a long time. They’ve figured out a way to live and manage.

Because of this, it is easy to miss whether someone truly has difficulty chewing. You can ask them if they have a problem chewing food, and the answer may be no. Because for them it isn’t a “problem.”

Know the Signs

Regardless of whether an older adult says they have difficulty chewing or not, it’s important to know what signs to look for.

Avoidance of certain foods, including meats, nuts, seeds, and other difficult to chew foods can be a sign they have difficulty chewing. Grimacing when eating is another sign. Unintended weight loss when you can’t pinpoint any other cause can be another sign of chewing difficulty.

Rather than just asking “do you have difficulty chewing”, try asking “are there any foods you avoid because you have a hard time eating them” or “does it hurt to eat certain foods” or “do you have pain in your mouth?”

If someone has pain in their mouth, they most certainly will have difficulty chewing.

How We Chew

Let’s talk about chewing. This may sound silly, but think about how you chew. A big part of chewing has to do with occlusion. What the heck is that?

Occlusion has to do with how your teeth align. Normal occlusion of the teeth is when you have molars on the top and bottom that meet when you bite. These teeth meeting is what crushes and grinds foods.

If you are missing teeth sporadically in the mouth, even though some teeth are present – if you don’t have teeth in the same spot on the top and bottom, it makes it difficult to chew.

Keep this in mind as we think about good oral care. If cavities take over the teeth and a tooth needs to be pulled, that missing tooth can make it harder to eat down the line.

Soft Foods for Elderly

The key to good nutrition is to eat a variety of foods every day. For older adults with chewing difficulty, soft foods can enable them to eat a wider variety of foods. Soft foods minimize or eliminate the need for chewing. Everyone is different, so find what works for the individual person.

Meats and protein foods are frequently a challenge to chew. Cutting meats into tiny pieces or blending them in a food processor can help. Try adding sauces or gravies to the chopped meats, because moisture can also help with eating.

Easy to chew protein foods include soft, cooked fish, cooked eggs, or tofu. Tuna or egg salad are also easy to chew (14).

Smoothies and shakes are a good way to add a lot of different foods into an easy to consume package. You can add fruits, vegetables, nuts, seeds, peanut butter, dairy – all kinds of good foods – into a blender and then drink them with a straw.

Soups are another great option to add a variety of easy to chew foods into your diet. Veggies and soft cooked or ground meats along with whole grains, beans, legumes, and lentils are a tasty addition to a homemade soup.

Supporting Seniors in Getting the Dental Care They Need

By now I hope you understand the impact that oral health can have on the nutritional well being and overall health of an older adult. This is an important issue that can be easy to over look in the everyday hustle of life.

If you are a family member, caregiver, or healthcare provider for an older adult, you probably want to know – what can I do to help?

Ways to Help

You can ask the question – are they having difficulty chewing? Be sure to ask in other ways as well and look for signs of difficulty chewing.

You can provide favorite foods that are easy to chew. Modify foods as needed, make meals with a variety of soft foods, and cut up foods before they are served.

You can ask how they are taking care of their dental health. Ask what help they may need.

You can help them get to the dentist through researching insurance or financial assistance programs in your area. And you can help by getting adaptive equipment as needed.

Be sure to have the older adult involved in interventions. Don’t just make changes across the board – make individualized changes that help them in their specific situation. And make sure these changes are things they want to do. Always be sure to respect the rights and choices of the older adult in your life.

We want to make sure our love and concern never crossed a line that disrespects an older adults’ dignity and autonomy (ability to make choices for themselves).

Assist with Oral Care

A big thing you can do is assist with oral care. This includes daily brushing and flossing and ensuring they get regular dental checkups. You can help with schedule dental appointments and arranging transportation to those visits as needed. If they are unable to afford to go to the dentist, you can help them to explore what options they have.

As mentioned earlier, if the older adult you are caring for has physical or cognitive decline you can help them brush and floss on a daily basis. It can be by providing verbal cuing for those with cognitive decline. Or helping to modify their toothbrush so they can brush their own teeth. And then providing physical assistance as needed.

The National Institute of Health has excellent information for caregivers onbrushingandflossing for older adults.

Insurance and Financial Assistance

Previously we covered how lack of insurance or finances is one of the biggest barriers to dental care among older adults. By now, I hope you realize how important regular dental care and check ups are. The cost of ignoring dental care now will have a high price later – both on the pocketbook and quality of life.

A word for health care professionals

As we are wrapping up this blog post, but I did want to add a little bit more for the health care professionals who are reading. Oral health is important, so think about how you are assessing for it in your practice.

Identifying Oral Health Needs is up to All of Us

Depending on your discipline and area of practice, how you approach dental health may vary. But we should all be talking about it.

Any healthcare professional can and should be identifying oral health needs in seniors and making referrals to dental care professionals as appropriate (15).

Health care professionals, including dietitians, should actually be looking at our patients’ mouths and asking them questions about their oral health. We should be providing education on what good oral health looks like for seniors.

Oral Exam and Nutrition Focused Physical Assessment

The oral assessment can be simple or complex. Simply looking in the mouth can help you to identify multiple issues – are any teeth missing, is there any visible decay, are the gums inflamed, are there are any sores, what is the health of the tongue?

Many dietitians have been trained on how to conduct an oral exam utilizing the nutrition-focused physical exam. In addition to noting any oral health concern, the dietitian can identify potential nutrient deficiencies and need for diet management (15).

If you are a dietitian, make it a point to learn how to conduct an oral health nutrition-focused physical exam and start using it in your practice.

Questions to Ask

What should you be asking your patients? At minimum ask about their issues with chewing. Some questions I may as in my assessment go beyond “Do you have any difficulty chewing?”

I also ask:

If you have dentures, do you take them out daily? Do you clean them? How long have you had them? How is the fit? Do you wear them while eating?

If they have any natural teeth, do you brush? Do you floss? When was the last time you saw the dentist?

Do you have any pain in your mouth?

Does it hurt to eat certain foods?

Do foods taste different?

If you don’t do an oral exam, be sure to ask about missing teeth, dentures, bridges, or potential sores.

You can get a lot more information if you just take a few minutes to dig deeper. This will give you greater knowledge into the status of oral health in your patients and help direct your education. Hopefully interventions can be made before serious dental issues occur.

If any issues are identified, be sure to document your findings, provide education as appropriate, and refer them to a dental health professional and support them with resources in your community if they have financial barriers to doing so. Identifying dental health issues is up to all of us.

Thank you for taking care of the dental health of our seniors!

(Feel free to use this infographic; please link back to this post and give credit to The Geriatric Dietitian!)

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About The Author

Katie Dodd, MS, RDN, CSG, LD, FAND is a Registered Dietitian and Board Certified Specialist in Gerontological Nutrition. She specializes in geriatrics, malnutrition, and end of life nutrition. Katie holds a Master’s degree in Food and Nutrition and is a Fellow of the Academy of Nutrition and Dietetics.

2 thoughts on “Nutrition Care Dental Health in Older Adults”

These are great tips for working with seniors! In our Diabetes & Nutrition Education Center, I work with a lot of older patients and this blog post definitely highlighted a few things about dentures and oral health that I hadn’t thought about before. Thank you for the useful information.